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Local vs. Systemic Effects of Aspirin
Which is more causal to peptic ulcers?
Aspirin (acetylsalicylic acid) has a multifactorial effect on the gastric mucosa and leads to gastrointestinal complications including ulcers. As a systemic cyclooxygenase inhibitor, it impairs the gastric mucosal barrier and inhibits platelet aggregation. As a weak acid, it also causes local damage to the gastric mucosa.
To determine if aspirin-induced ulcers are caused by local or systemic effects, investigators in the Netherlands used a national primary care database to retrospectively identify 11,891 patients who were taking aspirin (80 mg) and 7928 who were taking effervescent calcium carbasalate (ECC; 100 mg), a calcium salt of acetylsalicylic acid that does not have the same local effect as aspirin on the gastric mucosa. The incidence of endoscopically confirmed ulcers was determined from the database, and the time-dependent risk for developing a peptic ulcer was determined for each group.
A total of 115 ulcers were detected during an average follow-up of 1.9 years. The incidence of ulcers was 3.07 per 1000 person-years among aspirin users and 4.31 per 1000 person-years among ECC users. Ulcer risk did not differ significantly between the two groups (adjusted hazard ratio, 1.39; 95% CI, 0.92–2.12), leading the investigators to conclude that aspirin-induced ulcers are the result of systemic, rather than local, effects of low-dose aspirin.
Comment: Nonsteroidal anti-inflammatory drugs (NSAIDs), including aspirin, can produce ulcers through their systemic inhibition of cyclooxygenase and the resultant breakdown of the gastric mucosal barrier. Enteric coating of aspirin or other NSAIDs reduces the acute local mucosal injury, but it does not protect against the systemic effect. Although this retrospective study likely underestimates the actual incidence of ulcers and is subject to potential channeling bias, it supports the notion that the acute local injury that occurs with aspirin is superficial and is not necessary for the development of peptic ulcers. More importantly, simply protecting against these local effects does not reduce the risk for clinically significant ulcers.
— David J. Bjorkman, MD, MSPH (HSA), SM (Epid.)
Published in Journal Watch Gastroenterology April 11, 2008
Citation(s):
van Oijen MGH et al. Peptic ulcerations are related to systemic rather than local effects of low-dose aspirin. Clin Gastroenterol Hepatol 2008 Mar; 6:309.
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